Current Concepts in the Mandibular Condyle

Topic
Fracture Management Part II: Open Reduction
Versus Closed Reduction
Kang-Young Choi, Jung-Dug Yang, Ho-Yun Chung, Byung-Chae Cho
Department of Plastic and Reconstructive Surgery, Kyungpook National University School of Medicine, Daegu, Korea

In the treatment of mandibular condyle fracture, conservative treatment using closed Correspondence: Kang-Young Choi
Department of Plastic and
reduction or surgical treatment using open reduction can be used. Management of mandibular Reconstructive Surgery, Kyungpook
condylar fractures remains a source of ongoing controversy in oral and maxillofacial trauma. National University School of
For each type of condylar fracture,the treatment method must be chosen taking into Medicine, 130 Dongduk-ro, Jung-gu,
Daegu 700-721, Korea
consideration the presence of teeth, fracture height, patientsadaptation, patients masticatory Tel: +82-53-420-5685
system, disturbance of occlusal function, and deviation of the mandible. In the past, closed Fax: +82-53-425-3879
reduction with concomitant active physical therapy conducted after intermaxillary fixation E-mail: kychoi@knu.ac.kr
during the recovery period had been mainly used, but in recent years, open treatment of
condylar fractures with rigid internal fixation has become more common. The objective
of this review was to evaluate the main variables that determine the choice of an open or
This article was invited as part of a panel
closed method for treatment of condylar fractures, identifying their indications, advantages, presentation, which was one of the most
and disadvantages, and to appraise the current evidence regarding the effectiveness of highly rated sessions by participants, at
the 69th Congress of the Korean Society
interventions that are used in the management of fractures of the mandibular condyle. of Plastic and Reconstructive Surgeons
on November 11, 2011 in Seoul, Korea.
Keywords Jaw fixation techniques / Mandibular condyle / Mandibular fractures / Motion No potential conflict of interest relevant
therapy, continuous passive to this article was reported.

Received: 8 July 2012 Revised: 9 July 2012 Accepted: 10 July 2012

pISSN: 2234-6163 eISSN: 2234-6171 http://dx.doi.org/10.5999/aps.2012.39.4.301 Arch Plast Surg 2012;39:301-308

INTRODUCTION duction. Many researchers recommended closed reduction be-

In the past, closed reduction with concomitant active physical
therapy that is conducted after intermaxillary fixation during
recovery period had been mainly used. However, as it has dis-
advantages such as metastasis of the fractured bone by muscle
strength, abnormal occlusion due to inappropriate fixation, and
inappropriate function of the temporomandibular joint (TMJ)
due to disuse muscular atrophy caused by long-term intermaxil-
lary fixation, open reduction has recently drawn attention. In
particular, condyle fracture is satisfactorily treated by closed re-
cause of problems of surgical approach, such as infection, injury
of nerve and blood vessel, and scar formation [1-3]. However,
compared to previous open reduction, it has been currently
more widely used by minimizing complications such as TMJ
pain and arthritis, and mouth opening limitation via accurate
reduction of bony fragment with the development of surgical
instruments and surgical approaches.
However, it is still controversial over the selection of either
closed or open reduction to treat condyle fracture depending on
displacement severity and fracture site. Klotch and Lundy [4]

Copyright 2012 The Korean Society of Plastic and Reconstructive Surgeons

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/
licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. www.e-aps.org

301
Choi KY et al. Management of the condyle fracture
and Widmark et al. [5] reported that open reduction should be
conducted if fractured mandibular condyle is severely displaced,
and that closed reduction may be conducted considering vari-
ous factors such as elderly or pediatric patients, difficulty in the
conduct of open reduction under systemic anesthesia, no other
facial fracture, and secured stability of occlusion.
Haug and Assael [6] reported that no statistically significant
difference in occlusion status and complication such as man-
dibular movement restriction was found between open and
closed reductions for mandibular condyle fracture. Ellis et al. [7]
reported that complications such as intraoperative bleeding and
postoperative infection, facial nerve paralysis, functional disor-
der of the auriculotemporal nerve, and condyle growth disorder
significantly increased when open reduction was conducted to
treat condylar head and neck fractures, and that closed reduc-
tion was more advantageous than open reduction. Meanwhile,
Brown and Jones [8] conducted rigid fixation using mini plate,
reporting that no intermaxillary fixation was required. Tu and
Tenhulzen [9]. Reported that fracture fixation using mini plate
and screw shortened intermaxillary fixation period and pre-
vented the disuse atrophy of the masticatory muscle, thereby
achieving early opening, and that postoperative complications
significantly decreased. Jeter et al. [10] reported that relatively
satisfactory outcomes were obtained from closed reduction for
condyle fracture, but that this method could cause mouth open-
ing disorder, mandibular setback, temporomandibular pain, and
functional disorders after long period after injured. They recom-
mended that fracture reconstruction and rigid fixation via open
reduction should be conducted on patients with condyle frac-
ture to achieve immediate mouth opening movement, and that
maintaining of intraoral hygiene, improvement of nutritional
improvement, and normal pronunciation should be performed.
TREATMENT OF MANDIBULAR
CONDYLE FRACTURE ORIF VS. CRIMF
Closed reduction and functional therapy
Method
For closed reduction, intermaxillary fixation is conducted using
arch bar and wire, followed by maintaining of the fixation of the
maxilla and mandible for 2 to 4 weeks. After achieving stable
union of the factored site, a wire for intermaxillary fixation is
removed. Then, normal occlusion is induced after fixation us-
ing rubber, and soft diet is maintained for 2 weeks. Functional
therapy that consists of passive mandibular movement exercise
and mouth opening exercise is conducted and then clinical
outcomes are observed. For mouth opening exercise, the physi-
cian holds the molar and mandibular border of the fracture side
302
after standing behind the patient, and induces normal occlusion
and normal mandibular movement by traction to the anterior
inner inferior several times. At the same time, the patient opens
his/her mouse for him/herself, and applies counter-force us-
ing hands to avoid mandibular deviation. Initial intermaxillary
fixation period varies depending on literatures. The authors
conduct initial intermaxillary fixation in intracapsular fracture
patients aged less than 5 years for 2 weeks, in those aged 5 years
or higher for 4 weeks, and in extracapsular fracture patients aged
less than 8 years for 2 weeks.
Advantage
Closed reduction with functional therapy is a relatively safe
treatment. No injury of nerves and blood vessels occur during
the treatment, and no postoperative complications such as infec-
tion or scar occurs. In particular, complications such as fracture,
loss, and eruption delay of the growing teeth can be avoided in
pediatric patients as no tooth germ injury occurs because of no
establishment of the crown of the permanent teeth [11] (Figs.
1, 2).
Disadvantage
Long-term intermaxillary fixation has disadvantages of the injury
of the periodontal tissue and buccal mucosa, poor oral hygiene,
pronunciation disorder, imbalanced nutrition, mouth opening
disorder, and respiration disorder [12,13]. In the case of conser-
vative treatment using closed reduction, the growth disorder and
excessive growth of the injured mandible may occur due to inap-
propriate reduction of bone fragments [14,15] and the right and
left displacement of the mandibular ramus or mandibular devia-
tion upon opening may occur after conservative treatment [16]
(Fig. 3). Many studies reported that facial asymmetry or TMJ
disease may occur in pediatric patients aged 10 to 15 years due
to growth disorder or functional disorder, and that in particular,
the growth and functional disorders of the TMJ may occur in
20% to 25% of pediatric patients aged 7 to 10 years [17,18].
Open reduction
Method
There are various operation methods of open reduction for
madibular condyle fracture depending on fracture site and de-
gree of bone fragment displacement. In general, they include
preauricular approach, postauricular approach, submandibular
approch, Risdon approach, combined approach, and retroman-
dibular approach. Treatment type should be selected consider-
ing patients age, preference, fracture type, fracture of other sites,
and teeth status.
Vol. 39 / No. 4 / July 2012

Fig. 1. An 18-year-old man with condyle head fracture due to traffic accident

(A) Preoperative coronal view of 3D head computed tomography (CT). (B) Coronal view of 3D head CT after functional treatment for 4 weeks.

A B

Fig. 2. An 8-year-old girl with condyle head fracture due to slip down

Serial 3D head computed tomography (CT) was checked during closed reduction and functional therapy. (A) Preoperative axial view of 3D head CT. (B)
Axial view of 3D head CT after functional treatment for 2 months. (C) Axial view of 3D head CT after functional treatment for 4 months. (D) Preoperative
Coronal view of 3D head CT. (E) Coronal view of 3D head CT after functional treatment for 2 months. (F) Coronal view of 3D head CT after functional
treatment for 4 months.

A B C

D E F

Advantage bony fragment to the most ideal anatomical site by a direct ap-
Open reduction has advantages of the reduction of the displaced proach to the facture site. In addition, it can prevent complica-

303
Choi KY et al. Management of the condyle fracture

Fig. 3. A 39 years old woman with both condyle fracture due to traffic accident

(A) Intermaxillary fixation (IMF) with arch bar apply. (B) IMF and arch bar removal was done at postoperative 1 month. (C) After 2 years, the panorama
plain film was checked. Functional treatment was applied initially for 2 months.

A B C

Fig. 4. A 70 years old woman with subcondylar fracture due to slip down

(A) Preoperative intermaxillary fixation with arch bar apply. (B) Intraoperative finding. (C) Panorama plain film was checked at postoperative
6 months. The subcondylar fracture was corrected by open reductionand internal fixation using pre-auricular approach.

A B C

tions such as respiration disorder, pronunciation disorder, and
severe nutritional imbalance by shortening intermaxillary fixa-
tion period via rigid fixation.
Disadvantage
Open reduction is an invasive treatment, which may cause injury
of nerves or blood vessels during operation, and postoperative
complications including infection. In addition, it has permanent
scar though the surgery is conducted after designing the incision
line considering aesthesis.
Operative procedure
Preauricular approach
Preauricular approach reduces condyle fracture by incising 3
to 4 cm from the inferior border of the tragus toward external
auditory canal along the skin crease of the anterior part of the
external ear (Fig. 4). It provides an easier approach to high con-
dylar fracture such as intercapsular fracture, easy reduction of the
injured soft tissues of the TMJ, and reduction via a direct inspec-
tion of the appropriate relationship among the condyle, disc, and
joint with eyes. In particular, preauricular approach is very useful
for the case of the condyle fragment anteromedially displaced by
the pulling of the medial pterygoid [19]. However, an approach
to the mandibular angle fracture is very difficult if the mandible
should be pulled inferiorly to find the displaced proximal seg-
ment. Furthermore, as the amount of exposing the mandibular
ramus is very limited, rigid fixation using mini-plate is hard to be
conducted if fracture site is positioned inferiorly to the mandibu-
lar condyle neck.
Postauricular approach
The postauricular approach is a method that reducesthe condyle
fracture by incising from a site 3 mm posterior to the postau-
ricular curved region along the curved region, and by incising
the mastoid process inferiorly and the upper ear-attached region
superiorly. It can be used for the reduction of high condyle frac-
ture. This method has advantages of excellent aesthesis due to
the approach from the posterior side of the ear, avoiding injuries
ofthe facial nerve branch and superficial temporal artery, low
risk of parotid injury, and securing the surgical field for the TMJ
region. Meanwhile, it has disadvantages of a narrow surgical field
for mandibular condyle neck fracture, difficulty in using surgical
devices, complications such as external auditory canal stenosis,
tinnitus, infection and necrosis of auricular cartilage, permanent
auricular paresthesia due to injury of the external auditory canal,
and longer wound closure time compared to the preauricular
approach.
Submandibular approach
The submandibular approach reduces condyle fracture by con-

304
Vol. 39 / No. 4 / July 2012
ducting incision from a site 2 to 3 cm inferior to the mandibular
inferior border, parallelly to the mandibular inferior border or
along with the skin crease. Due to its easier approach to the
mandibular ramus, inferior mandibular condyle, and coronoid
notch, it is commonly used for mandibular condyle fracture.
However, it has disadvantages of requiring excessive traction for
reducing mandibular condyle fracture, requiring rigid fixation
using percutaneous trocar for reducing high condyle fracture
due to difficulty in an direct approach to the site of the fracture
line formed, and requiring deep tunneling for mandibular con-
dyle fracture due to a long distance from the incision line to the
fixation site, and requiring the use of mini-plate due to poorly
secured surgery field. Furthermore, it has disadvantages of the
possible risk of the injury of inferior alveolar branch of the facial
nerve, submandibular scar formation, difficulty in approaching
the high condyle fracture site, and difficulty in examining the
internal structure of the TMJ.
Risdon approach
Risdon approach is a method similar to submandibular ap-
proach. It can easily approach to the inferior region, ramus, goni-
al angle and posterior body of the mandibular condyle. If the up-
per flap is intensively retracted, even mandibular condyle inferior
and neck fractures can be exposed. Reduction of bone fragments
can be easily conducted by traction the mandibular gonial angle
inferiorly. Meanwhile, like submandibular approach, Risdon ap-
proach requires excessive traction for high condyle fracture [20].
Combined approach
This method reduces both inferior and superior fractures of
the mandibular condyle by applying preauricular approach
and submandibular approach simultaneously. This method is
very useful as mandibular subcondyle fracture is reduced using
submandibular approach, and the superior fractures of the TMJ
or mandibular condyle neck is approached via preauricular
approach and bone fragments are reduced while putting in trac-
tion the mandible inferiorly. Meanwhile, due to the use of two
approaches, combined approach has disadvantages of relatively
longer operation time, large scar formation, high risk of the
injury of facial nerve, and risk of secondary TMJ disease due to
scar formation on the TMJ capsule by preauricular approach.
Intraoral approach
Intraoral approach reaches the mandibular condyle in a way
similar to vertical ramus osteotomy. The incision line is formed
along the anterior mandibular ramus and buccal sulcus. For the
achievement of surgery field and device approach, the tempora-
lis muscle attached to the mandibular ramus and the periosteum
of the buccinator located at the body should be completely dis-
sected to elevate them. This method has advantages of no scar
formation and the minimum injury of facial nerves. Meanwhile,
an approach using devices is difficult though operation field is
secured using an endoscope. Furthermore, percutaneous trocar
should be used for rigid fixation using metal plate after reduc-
tion. It has disadvantages of difficulties in the maintaining of
bone fragment stability and in the observation of the internal
structure of the TMJ for mandibular subcondyle fracture [10].
Retromandibualar approach
Retromandibualar approach reduces condyle fracture by dis-
secting the skin and subcutaneous tissue vertically to the man-
dibular angle using the 3-cm incision line to the 5 mm inferior
to the auricular lobe. This method provides easy reduction and
rigid fixation for mandibular subcondyle fracture. Percutane-
ous trocar is not required as the method can tract the tissues
anteriorly and superiorly at the sigmoid notch. It also provides
reduction and rigid fixation for high condyle fracture, where in-
cision length is small. Furthermore, this method has advantages
of insignificant scar formation due to the incision made at the
posterior mandibular ramus, and the sufficient exposure of bone
fragments to the upper part of the mandibular ramus. However,
it has disadvantages of risk of the injury of facial nerves and
bleeding caused by the injury of blood vessels [20,21].
Final check point after open reduction
For the reduction of facial bone fracture, the authors suggest that
after reducing other elements according to centric occlu con-
dyle (CO) with normal functions should be identified, followed
by performing the condyle fracture reduction. The sequence of
reduction, however, is somewhat controversial. If reduction is
conducted according to the fracture line and condyle type prior
to other occlusion-related fracture, the result of subsequent
reduction to other elements according to CO may cause occlu-
sion interference during the normal movement of the mandible.
In that case, trauma from occlusion (TFO) eventually occurs,
thereby causing problems in the oral and maxillofacial system.
After facial bone surgery related to occlusion, disorders of
functional movement that might occur later should be checked.
In fact, as it is difficult to observe normal movement of the man-
dible and occlusal interference under systemic anesthesia, it is
difficult to assess the aforementioned disorders. This is done by
checking the disorder of mandibular functional movement after
reduction according to CO. when mouth opening is performed
by holding the mandible with hands, translation movement oc-
curs after appropriate rotation movement. At that point, if con-
dyle head movement is palpitated at the preauricular area, man-
305
Choi KY et al. Management of the condyle fracture
dibular movement at the sagittal plane is considered good. No
deflection of mandibular movement should occur at this point.
Next, guidance teeth are identified from anterior and lateral
movement after checking the attrition status of the occlusion sur-
face. If the guidance teeth found during mandibular movement
by maintaining the contact of the maxillary and mandibular teeth
by holding the mandible with hands, and the guidance teeth dur-
ing movement are identical, and if no premature contact occur in
other teeth, functional movement is expected to be normal.
GUIDELINE OF TREATMENT
Mandibular condyle fracture is the most common fracture
among mandibular fractures, the treatment methods for man-
dibular condyle fracture have been controversial. Since Zide
and Kent [1] reported the relative and absolute indications of
mandibular condyle fracture in 1983, open reduction via surgery
has become controversial, and the new approaches of surgical
reduction and fixation have been introduced and developed.
In particular, mandibular condyle fracture occurs by various
causative factors, and has various treatment methods depend-
ing on the fracture location, patients age, and fracture type.
However, regardless ofthe treatment option, the purpose of the
treatment of mandibular condyle fracture is to recover normal
TMJ function via the reconstruction of appropriate anatomical
position. Thus, assessment of treatment success, as well as the
outcomes of an early treatment, should be conducted based on
complications such as TMJ derangement, ankylosis of TMJ, or
growth disorder via long-term follow-up. Therefore, it is impor-
tant to control functional complications and aesthetic problems
from a long-term perspective. The final goal of the treatment lies
in the achievement of occlusal stability, normal mouth opening,
normal TMJ movement, prevention of temporomandibular
Table 1. Zide and Kents indications for open reduction (1983)
Absolute Indicaton
Displacement into middle cranial fossa
Impossibility of obtaining adequate occlusion by closed reduction
Lateral extracapsular displacement
Invasion by foreign body
Relative Indication
Bilateral condylar fractures in an edentulous patient without a splint
Unilateral or bilateral condylar fractures where splinting cannot be accomplished
for medical reasons or because physiotherapy is Impossible
Bilateral condylar fractures with communited midfacial fractures, prognathisim or
retroprognathism
Periodontal problems
Loss of teeth
Unilateral condylar fracture with unstable base
From Zide and Kent, with permission from Elsevier [1].
306
joint derangement and joint pain, and prevention of growth dis-
order in patients with mandibular fracture by selecting an appro-
priate treatment method between closed and open reductions.
Zide and Kents indication of open reduction (1983)
For indications of open reduction on mandibular condyle
fracture, Zide and Kent [1] suggested that absolute indications
should include displacement into middle cranial fossa, inap-
propriate occlusal restoration by closed reduction, lateral extra-
capsular displacement, and foreign material of the fracture site,
and that relative indications should include bilateral mandibular
condyle fracture of edentulous patients who can not have splint,
impossible intermaxillary fixation and physical therapy due to
internal diseases, bilateral mandibular condyle fracture with
comminuted fracture of other facial bone, and bilateral mandib-
ular condyle fracture with jaw deformities (Table 1). They also
suggested that factors involved in the selection of open reduc-
tion include the location of the displaced mandibular condyle,
fracture site, time delayed after fracture, patients individual char-
acteristics, edema severity, selection of incision line, and fixation
type.
Mathes (1983)
Klotch and Lundy [4] and Choi et al. [22-24] suggested that
angulation between the fractured fragments in excess of 30
degrees and fracture gap between the bone ends exceeding 4 or
5 mm, lateral override, and lack of contact of the fractured frag-
ments should be considered before justifying open reduction
(Table 2) [25].
Table 2. Treatment protocol (Mathes)
Open Reduction Indication
Malocclusion with CR
Fragment angulation: more 30
Bone gap: more 4-5 mm
Lateral override
Lack of contact of the fracture fragment
Preferred for Open Reduction
Any low, dislocated subcondylar fracture
Low condylar fracture with multiple fractured mandible or maxillary or Le Fort
fracture
Low condylar fracture with displacement of condylar head out of the glenoid fossa
Condylar fragment 14- medial tilt
Ramus shortening - 5%
Bilateral fracture with open bite
Gross fracture end malalignment
Fracture - dislocation
Abnormal function, malocclusion
From Mathes and Hentz, with permission from Elsevier [24].
Vol. 39 / No. 4 / July 2012
Table 3. AAOMS special committee on parameters of care
indications for open reduction (2003)
Physical evidence of fracture
Imaging evidence of fracture
Malocclusion
Mandibular dysfuncton
Abnormal relationship of jaw
Presence of foreign bodies
Lacerations and/or hemorrhage in external auditory canal
Hemotympanum
Cerebrospinal fluid otorrhea
Effusion
Hamarthrosis
Permission from American Association of Oral and Maxillofacial Surgeons [26].
AAOMS (2003)
In 2003, American Association of Oral and Maxillofacial Sur-
gery suggested an international guideline on the treatment of
mandibular condyle fracture. According to the guideline, open
reduction is recommended for the cases of mandibular condyle
fracture suspected in clinical and radiologic examinations to
prevent complications such as functional or growth disorders
(Table 3) [26].
Authors method
Researchers supporting open reduction on mandibular condyle
fracture report that the anatomically and functionally accurate
reconstruction of bone fragments is important. Despite the good
outcomes of conservative treatment, mouth opening deflection
and chronic dull pain may occur during a long-term follow-up.
Thus, open reduction is recommended for the cases of indica-
tion of open reduction, difficulty in the appropriate treatment of
fracture via closed reduction, and high risk of complication after
mandibular condyle fracture (Fig. 5).
For the treatment of mandibular condyle fracture in pediatric
patients, anatomical structure and physiological and psychiat-
ric development should be considered as they differ between
pediatric and adult patients though pathogenesis and clinical
manifestation are similar between the two groups. Pediatric pa-
tients have the facial bone covered with thick soft tissues, elastic
bone structure, and the thin cortical bone and also have a large
amount of premature trabecular bone. Thus, no severe impact
occurs upon receiving trauma. In general, incomplete fracture
with a greenstick type occurs [27].
As teeth alignment has a status of primary or mixed dentition,
and most of the growing crown of the permanent tooth has not
been completely established yet, the ratio of bone tissue to the
tooth is relatively low. Thus, un-erupted teeth are easily included
in the fracture line, and complications such as the fracture, loss,
Fig. 5. Authorss algorithm for open reduction (2012)
IMF, intermaxillary fixation.
Condyle fracture
Intra capsular Extra capsular
< 5 yr > 5 yr < 5-8 yr
> 5-8 yr
: IMF (0-2 wk) : IMF (2-4 wk) : IMF (0-2 wk)
First: Open Reduction
Closed treatment If, impossible
Functional treatment 3-6 wk IMF
+ 4 wk Functional treatment
+ 3 mo follow-up
delayed eruption of the growing tooth may occur if unerupted
permanent teeth are injured. If the intermaxillary fixation pe-
riod is maintained for 2 weeks or more, mandibular growth
disorder and the injury of the teeth undergoing eruption may
occur. Thus, in pediatric patient, open reduction of the condyle
is invasive for itself, and has a risk of facial nerve injury. Further-
more, no significant difference in prognosis is found compared
to closed reduction. Thus, a non-surgical approach is recom-
mended, in which intermaxillary fixation period should be 2
weeks or less.
Accordingly, the authors principally conduct functional ther-
apy after closed reduction for intracapsular fracture in the treat-
ment of mandibular condyle fracture. Intermaxillary fixation is
maintained for 2 weeks in patients aged less than 5 years, and
for 2 to 4 weeks in patients aged 5 years or higher depending
on physical development and patient compliance. In the case
of extracapsular mandibular condyle fracture, closed reduction
is conduced, followed by functional therapy after 2-week inter-
maxillary fixation in patients aged 5 to 8 years. Meanwhile, open
reduction is preferentially considered in patients aged 8 years or
higher. If open reduction is impossible, closed reduction is con-
ducted, followed by 4-week functional therapy after 3 to 6-week
intermaxillary fixation. Then, occlusion and TMJ dysfunction
are carefully observed every 3 months (Fig. 5).
CONCLUSIONS
In the treatment of mandibular condyle fracture, conservative
treatment using closed reduction and surgical treatment using
open reduction are used. However, it is still controversial over
indications. Thus, treatment type should be selected consider-
ing patients age, fracture type, patients systemic status, other
fracture, teeth, and possibility of occlusal restoration by inter-
307
Choi KY et al. Management of the condyle fracture
maxillary fixation, and existence of foreign materials. In the final
determination of treatment plan, the advantage, disadvantage,
and risk of each treatment, and risk of complications should
be sufficiently discussed with patients and patients guardians.
In addition, the treatment plan of mandibular condyle fracture
should be established considering the aforementioned various
factors rather than the criteria for absolute indications using the
treatment guideline suggested by the authors.
REFERENCES
1. Zide MF, Kent JN. Indications for open reduction of man-
dibular condyle fractures. J Oral Maxillofac Surg 1983;41:
89-98.
2. Goss AN, Bosanquet AG. The arthroscopic appearance of
acute temporomandibular joint trauma. J Oral Maxillofac
Surg 1990;48:780-3.
3. Wood GD. Assessment of function following fracture of the
mandible. Br Dent J 1980;149:137-41.
4. Klotch DW, Lundy LB. Condylar neck fractures of the man-
dible. Otolaryngol Clin North Am 1991;24:181-94.
5. Widmark G, Bagenholm T, Kahnberg KE, et al. Open re-
duction of subcondylar fractures: a study of functional reha-
bilitation. Int J Oral Maxillofac Surg 1996;25:107-11.
6. Haug RH, Assael LA. Outcomes of open versus closed treat-
ment of mandibular subcondylar fractures. J Oral Maxillofac
Surg 2001;59:370-5.
7. Ellis E 3rd, McFadden D, Simon P, et al. Surgical complica-
tions with open treatment of mandibular condylar process
fractures. J Oral Maxillofac Surg 2000;58:950-8.
8. Brown JS, Jones K. Delayed miniplate osteosynthesis for
mandibular fractures. Br J Oral Maxillofac Surg 1991;29:
286.
9. Tu HK, Tenhulzen D. Compression osteosynthesis of man-
dibular fractures: a retrospective study. J Oral Maxillofac
Surg 1985;43:585-9.
10. Jeter TS, Van Sickels JE, Nishioka GJ. Intraoral open reduc-
tion with rigid internal fixation of mandibular subcondylar
fractures. J Oral Maxillofac Surg 1988;46:1113-6.
11. Kaban LB, Troulis MJ. Pediatric oral and maxillofacial sur-
gery. Philadelphia: Saunders; 2004.
12. Coletti DP, Salama A, Caccamese JF Jr. Application of in-
termaxillary fixation screws in maxillofacial trauma. J Oral
Maxillofac Surg 2007;65:1746-50.
308
13. Gaujac C, Ceccheti MM, Yonezaki F, et al. Comparative
analysis of 2 techniques of double-gloving protection during
arch bar placement for intermaxillary fixation. J Oral Maxil-
lofac Surg 2007;65:1922-5.
14. Khosla M, Boren W. Mandibular fractures in children and
their management. J Oral Surg 1971;29:116-21.
15. Dahlstrom L, Kahnberg KE, Lindahl L. 15 years follow-up
on condylar fractures. Int J Oral Maxillofac Surg 1989;18:
18-23.
16. Norholt SE, Krishnan V, Sindet-Pedersen S, et al. Pediatric
condylar fractures: a long-term follow-up study of 55 pa-
tients. J Oral Maxillofac Surg 1993;51:1302-10.
17. Kaban LB. Diagnosis and treatment of fractures of the fa-
cial bones in children 1943-1993. J Oral Maxillofac Surg
1993;51:722-9.
18. Kahl B, Fischbach R, Gerlach KL. Temporomandibular
joint morphology in children after treatment of condylar
fractures with functional appliance therapy: a follow-up
study us computed tomography. Dentomaxillofac Radiol
1995;24:37-45.
19. Chuong R, Piper MA. Open reduction of condylar fractions
of the mandible in conjunction with repair of discal injury: a
preliminary report. J Oral Maxillofac Surg 1988;46:257-63.
20. Ellis E 3rd, Dean J. Rigid fixation of mandibular condyle
fractures. Oral Surg Oral Med Oral Pathol 1993;76:6-15.
21. Ellis E, Zide MF, Manson PN. Surgical approaches to the
facial skeleton. Baltimore: Williams & Wilkins; 1995.
22. Choi BH, Kim KN, Kim HJ, et al. Evaluation of condylar
neck fracture plating techniques. J Craniomaxillofac Surg
1999;27:109-12.
23. Choi BH, Yoo JH. Open reduction of condylar neck frac-
tures with exposure of the facial nerve. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 1999;88:292-6.
24. Choi BH, Yi CK, Yoo JH. Clinical evaluation of 3 types of
plate osteosynthesis for fixation of condylar neck fractures. J
Oral Maxillofac Surg 2001;59:734-7.
25. Mathes SJ, Hentz VR. Plastic surgery. 2nd ed. Philadelphia:
Saunders Elsevier; 2006.
26. American Association of Oral and Maxillofacial Surgeons
[Internet]. Rosemont: American Association of Oral and
Maxillofacial Surgeons; c2012 [cited 2012 Jul 7]. Avaiable
from: http://http://www.aaoms.org/.
27. Guven O, Keskin A. Remodelling following condylar frac-
tures in children. J Craniomaxillofac Surg 2001;29:232-7.